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| {{Diabetes}}
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| {{Infobox_Disease | | | {{Infobox_Disease | |
| Name = {{PAGENAME}} | | | Name = {{PAGENAME}} | |
| Image = Nodular_glomerulosclerosis.jpeg | | | Image = Nodular_glomerulosclerosis.jpeg | |
| Caption = Photomicrography of nodular glomerulosclerosis in Kimmelstein-Wilson syndrome. Source: CDC | | | Caption = Photomicrography of nodular glomerulosclerosis in Kimmelstein-Wilson syndrome. Source: CDC | |
| DiseasesDB = |
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| ICD10 = E10.2, E11.2, E12.2, E13.2, E14.2 |
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| ICD9 = {{ICD9|250.4}} |
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| ICDO = |
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| OMIM = |
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| MedlinePlus = |
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| eMedicineSubj = |
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| eMedicineTopic = |
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| MeshID = D003928 |
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| }} | | }} |
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| '''For patient information click [[{{PAGENAME}} (patient information)|here]]''' | | '''For patient information click [[{{PAGENAME}} (patient information)|here]]''' |
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| {{SI}} | | {{Diabetic nephropathy}} |
| {{CMG}}
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| ==Overview==
| | {{CMG}}, {{APM}}; {{AE}} {{OO}} |
| '''Diabetic nephropathy''' (''nephropatia diabetica''), also known as '''Kimmelstiel-Wilson syndrome''' and '''intercapillary glomerulonephritis''', is a progressive [[kidney disease]] caused by [[angiopathy]] of [[capillary|capillaries]] in the [[kidney]] [[glomerulus|glomeruli]]. It is characterized by [[nephrotic syndrome]] and nodular glomerulosclerosis. It is due to longstanding [[diabetes mellitus]], and is a prime cause for [[dialysis]] in many Western countries.
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| ==History==
| | {{SK}}: Kimmelstiel-Wilson disease; diabetic glomerulosclerosis; nephropathy-diabetic; diabetic glomerulonephropathy |
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| The syndrome was discovered by British [[physician]] Clifford Wilson (1906-1997) and Germany-born American physician Paul Kimmelstiel (1900-1970) and was published for the first time in 1936.
| | ==[[Diabetic nephropathy overview|Overview]]== |
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| ==Epidemiology== | | ==[[Diabetic nephropathy historical perspective|Historical Perspective]]== |
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| The syndrome can be seen in patients with [[chronic (medicine)|chronic]] [[diabetes]] (15 years or more after onset), so patients are usually of older age (between 50 and 70 years old). The disease is progressive and may cause [[death]] two or three years after the initial lesions, and is more frequent in men. Diabetic nephropathy is the most common cause of chronic kidney failure and end-stage kidney disease in the United States. People with both type 1 and type 2 diabetes are at risk. The risk is higher if blood-glucose levels are poorly controlled. Further, once nephropathy develops, the greatest rate of progression is seen in patients with poor control of their blood pressure. Also people with high cholesterol level in their blood have much more risk than others.
| | ==[[Diabetic nephropathy classification|Classification]]== |
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| ==Etiopathology== | | ==[[Diabetic nephropathy pathophysiology|Pathophysiology]]== |
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| The earliest detectable change in the course of diabetic nephropathy is a thickening in the glomerulus. At this stage, the kidney may start allowing more [[serum albumin]] (plasma protein) than normal in the [[urine]] ([[albuminuria]]), and this can be detected by sensitive [[medical test]]s for albumin. This stage is called "microalbuminuria". It can appear 5 to 10 years before other symptoms develop. As diabetic nephropathy progresses, increasing numbers of glomeruli are destroyed by nodular glomerulosclerosis. Now the amounts of albumin being excreted in the urine increases, and may be detected by ordinary [[urinalysis]] techniques. At this stage, a kidney [[biopsy]] clearly shows diabetic nephropathy.
| | ==[[Diabetic nephropathy causes|Causes]]== |
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| ==Signs and symptoms== | | ==[[Differentiating Diabetic nephropathy from other diseases|Differentiating Diabetic nephropathy from other Diseases]]== |
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| Kidney failure provoked by glomerulosclerosis leads to fluid filtration deficits and other disorders of kidney function. There is an increase in [[blood pressure]] ([[hypertension]]) and of fluid retention in the body ([[oedema]]). Other [[complication (medicine)|complications]] may be [[arteriosclerosis]] of the [[renal artery]] and [[proteinuria]] (nephrotic syndrome).
| | ==[[Diabetic nephropathy epidemiology and demographics|Epidemiology and Demographics]]== |
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| Throughout its early course, diabetic nephropathy has no [[symptom]]s. They develop in late stages and may be a result of excretion of high amounts of protein in the urine or due to renal failure:
| | ==[[Diabetic nephropathy risk factors|Risk Factors]]== |
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| * [[edema]]: swelling, usually around the [[eye]]s in the mornings; later, general body swelling may result, such as swelling of the legs
| | ==[[Diabetic nephropathy screening|Screening]]== |
| * foamy appearance or excessive frothing of the urine
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| * unintentional weight gain (from fluid accumulation)
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| * [[anorexia (symptom)|anorexia]] (poor appetite)
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| * [[nausea]] and [[vomiting]]
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| * [[malaise]] (general ill feeling)
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| * [[fatigue (physical)|fatigue]]
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| * [[headache]]
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| * frequent [[hiccup]]s
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| * generalized [[itching]]
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| The first laboratory abnormality is a positive microalbuminuria test. Most often, the diagnosis is suspected when a routine urinalysis of a person with diabetes shows too much protein in the urine (proteinuria). The urinalysis may also show [[glucose]] in the urine, especially if blood glucose is poorly controlled. Serum [[creatinine]] and [[BUN]] may increase as kidney damage progresses.
| | ==[[Diabetic nephropathy natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
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| A kidney [[biopsy]] confirms the diagnosis, although it is not always necessary if the case is straightforward, with a documented progression of proteinuria over time and presence of diabetic [[retinopathy]] on examination of the [[retina]] of the [[eye]]s.
| | ==Diagnosis== |
| | [[Diabetic nephropathy history and symptoms|History and Symptoms]] | [[Diabetic nephropathy physical examination|Physical Examination]] | [[Diabetic nephropathy laboratory findings|Laboratory Findings]] | [[Diabetic nephropathy electrocardiogram|Electrocardiogram]] | [[Hashiomoto's thyroiditis chest x ray|Chest X Ray]] | [[Diabetic nephropathy CT|CT]] | [[Diabetic nephropathy MRI|MRI]] | [[Diabetic nephropathy echocardiography or ultrasound|Echocardiography or Ultrasound]] | [[Diabetic nephropathy other imaging findings|Other Imaging Findings]] | [[Diabetic nephropathy other diagnostic studies|Other Diagnostic Studies]] |
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| ==Treatment== | | ==Treatment== |
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| The goals of treatment are to slow the progression of kidney damage and control related complications. The main treatment, once proteinuria is established, is [[ACE inhibitor]] drugs, which usually reduces proteinuria levels and slows the progression of diabetic nephropathy. Several effects of the ACEIs that may contribute to renal protection have been related to the association of rise in Kinins which is also responsible for some of the side effects associated with ACEIs therapy such as dry cough. The renal protection effect is related to the antihypertensive effects in normal and hypertensive patients, renal vasodilatation resulting in increased renal blood flow and dilatation of the efferent arterioles. [http://www.ksu.edu.sa/sites/Colleges/Medicine/Lists/Medical%20Subjects/Flat.aspx?RootFolder=http%3a%2f%2fwww%2eksu%2eedu%2esa%2fsites%2fColleges%2fMedicine%2fLists%2fMedical%20Subjects%2fDiabetes%20Mellitus%20and%20Angiotensin%20Converting%20Enzyme%20Inhibitors&FolderCTID=0x01200200CEDE56CEF8D11C46824F2F6116DF88AA] Many studies have shown that related drugs, [[angiotensin receptor blocker]]s (ARBs), have a similar benefit. In fact, a combination may be best.
| | [[Diabetic nephropathy medical therapy|Medical Therapy]] | [[Diabetic nephropathy surgery|Surgery]] | [[Diabetic nephropathy primary prevention|Primary Prevention]] | [[Diabetic nephropathy secondary prevention|Secondary Prevention]] | [[Diabetic nephropathy cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Diabetic nephropathy future or investigational therapies|Future or Investigational Therapies]] |
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| Blood-glucose levels should be closely monitored and controlled. This may slow the progression of the disorder, especially in the very early ("microalbuminuria") stages. Medications to manage diabetes include oral hypoglycemic agents and [[insulin]] injections. As kidney failure progresses, less insulin is excreted, so smaller doses may be needed to control glucose levels.
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| The [[diet (nutrition)|diet]] may be modified to help control blood-sugar levels. Modification of protein intake can effect hemodynamic and nonhemodynamic injury.
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| High blood pressure should be aggressively treated with antihypertensive medications, in order to reduce the risks of kidney, eye, and blood vessel damage in the body. It is also very important to control lipid levels, maintain a healthy weight, and engage in regular physical activity.
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| Patients with diabetic nephropathy should avoid taking the following drugs:
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| * Contrast agents containing [[iodine]]
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| * Commonly used non-steroidal anti-inflammatory drugs ([[NSAID]]s) like [[ibuprofen]] and [[naproxen]], or [[COX-2]] inhibitors like [[Celebrex]], because they may injure the weakened kidney.
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| [[Urinary tract]] and other [[infections]] are common and can be treated with appropriate [[antibiotics]].
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| [[Dialysis]] may be necessary once end-stage renal disease develops. At this stage, a [[kidney transplantation]] must be considered. Another option for type 1 diabetes patients is a combined kidney-pancreas transplant.
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| [[C-peptide]], a by-product of insulin production, may provide new hope for patients sufering from diabetic nephropathy <ref>[http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&list_uids=17235526&cmd=Retrieve&indexed=google C-peptide is a bioactive peptide. [Diabetologia. 2007] - PubMed Result<!-- Bot generated title -->]</ref> <ref>{{cite journal |author=Wahren J, Ekberg K, Jörnvall H |title=C-peptide is a bioactive peptide |journal=Diabetologia |volume=50 |issue=3 |pages=503–9 |year=2007 |pmid=17235526 |doi=10.1007/s00125-006-0559-y |url=}}</ref>. | |
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| ==Prognosis==
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| Diabetic nephropathy continues to get gradually worse. Complications of chronic kidney failure are more likely to occur earlier, and progress more rapidly, when it is caused by diabetes than other causes. Even after initiation of dialysis or after transplantation, people with diabetes tend to do worse than those without diabetes.
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| ==Complications==
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| Possible complications include:
| | ==Case Studies== |
| | | [[Diabetic nephropathy case study one|Case #1]] |
| * [[hypoglycemia]] (from decreased excretion of insulin)
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| * rapidly progressing chronic [[kidney failure]]
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| * [[end-stage kidney disease]]
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| * [[hyperkalemia]]
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| * severe [[hypertension]]
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| * complications of [[hemodialysis]]
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| * complications of [[kidney transplant]]
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| * coexistence of other [[diabetes]] complications
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| * [[peritonitis]] (if peritoneal dialysis used)
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| * increased [[infections]]
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| ==Additional images== | |
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| <gallery>Image:Diabetic glomerulosclerosis (1) HE.jpg|Histopathological image of diabetic glomerulosclerosis with nephrotic syndrome. H&E stain.
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| Image:Diabetic glomerulosclerosis (2) HE.jpg|Histopathological image of diabetic glomerulosclerosis with nephrotic syndrome. Another glomerulus. H&E stain.
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| Image:Diabetic glomerulosclerosis (3) HE.jpg|Histopathological image of diabetic glomerulosclerosis with nephrotic syndrome. Another glomerulus. H&E stain.
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| Image:Diabetic glomerulosclerosis (4) PAS.jpg|Histopathological image of diabetic glomerulosclerosis with nephrotic syndrome. PAS stain.
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| Image:Diabetic glomerulosclerosis (5) PAS.jpg|Histopathological image of diabetic glomerulosclerosis with nephrotic syndrome. PAS stain.
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| Image:Diabetic glomerulosclerosis (7) PAM.jpg|Histopathological image of diabetic glomerulosclerosis with nephrotic syndrome. PAM stain.
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| Image:Diabetic glomerulosclerosis (8) PAM.jpg|Histopathological image of diabetic glomerulosclerosis with nephrotic syndrome. PAM stain.
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| </gallery>
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| ==References==
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| {{Reflist}}
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| ==Additional Resource==
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| * Kimmelstiel P, Wilson C. ''Benign and malignant hypertension and nephrosclerosis. A clinical and pathological study.'' Am J Pathol 1936;12:45-48.
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| ==External links== | | ==External links== |
| * [http://www.healthcentral.com/mhc/top/000494.cfm Diabetic nephropathy]. HealthCentral.
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| * [http://www.nlm.nih.gov/medlineplus/ency/article/000494.htm Diabetic nephropathy]. MedlinePlus Medical Encyclopedia. Text from this public domain article was partially used here. | | * [http://www.nlm.nih.gov/medlineplus/ency/article/000494.htm Diabetic nephropathy]. MedlinePlus Medical Encyclopedia. Text from this public domain article was partially used here. |
| * [http://www.podomedic.it/modules/news/article.php?storyid=108 Texas University Classification]
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| {{Nephrology}} | | {{Nephrology}} |
| {{Endocrine pathology}} | | {{Endocrine pathology}} |
| | {{Diabetes}} |
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| | | [[Category:Pediatrics]] |
| [[Category:Kidney diseases]] | | [[Category:Endocrinology]] |
| [[Category:Angiology]] | | [[Category:Nephrology]] |
| [[Category:Diabetes]] | |
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| [[de:Diabetische Nephropathie]] | | [[de:Diabetische Nephropathie]] |
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| [[sv:Diabetesnefropati]] | | [[sv:Diabetesnefropati]] |
| [[Category:Mature chapter]] | | [[Category:Mature chapter]] |
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| {{WH}} | | {{WH}} |
| {{WS}} | | {{WS}} |
